Independent Practice Authority for NPs Could Further Fragment Care

Granting nurse practitioners (NPs) independent practice authority would undermine the concept of team-based collaborative care, while further fragmenting an already disjointed U.S. health care system. That was one of the main messages delivered by AAFP Director Wanda Filer, M.D., of York, Pa., during a March 19 policy forum(www.politico.com) here that addressed scope-of-practice issues.

According to Filer, who spoke as part of a five-member panel during the event hosted by Washington-based news organization Politico Pro, granting NPs independent prescribing authority reflects a silo-based approach to health care that does not serve patients well. "We need to get away from the old system of fragmented care and really work on team-based care," she said.

Filer, who practices at a federally qualified health center, said she regularly works alongside NPs and physician assistants as part of a comprehensive health care team that delivers and coordinates patient care.

"I have nurse practitioner colleagues and physician assistant colleagues who work right next to me, and they are incredibly valuable for the patients that we all care so much about," said Filer.

Still, physicians' extensive training and expertise best qualify them to lead the health care team, according to Filer. She cited the physician-led patient-centered medical home as the best example of a collaborative, team-based approach to care.

Filer appeared on the panel with Angela Golden, D.N.P., president of the American Association of Nurse Practitioners; Dan Hawkins, senior vice president of public policy and research for the National Association of Community Health Centers; Terie Norelli, president of the National Conference of State Legislatures; and Donna Shalala, Ph.D., former secretary of HHS.

Golden said her organization also supports team-based care, but it opposes regulations that require NPs to be "supervised by another provider or another professional."

"We believe team-based care is critical, but we don't believe it should be regulated," said Golden.

Filer maintained, however, that independent practice authority for NPs is not in the best interest of patients. As an example, she cited a story from her own practice, saying that a few weeks ago one of her NP colleagues acknowledged she lacked the expertise to treat a "complicated patient."

"I said to (the NP), 'I would be happy to take over the care of that patient,'" said Filer.

Filer spent the next 45 minutes with the patient, while the NP was able to see three other patients during that same period.

"That is why working side-by-side in a team-based approach is really in the best interest of the patients," said Filer.

Some of the panelists contended that independent practice authority for NPs would alleviate access-to-care issues, which are expected to worsen as more patients seek health care services provided through the Patient Protection and Affordable Care Act. Filer noted, however, that "data suggest that if we could have four nurse practitioners for every family physician, we could eliminate a lot of the access issues we already have."

"We need a lot more family physicians, we need a lot more primary care nurse practitioners and we need more primary care physician assistants," said Filer. "(Patients) are expecting and deserve good, quality care."

Shalala, meanwhile, cautioned against "bringing the cost of care" into the debate about scope-of-practice issues.

"There are a lot of ways we can pull costs out of the system. I would not want to get into a discussion that we substitute nurses for docs" as a way of saving money, said Shalala.